ICU经鼻置管患者鼻黏膜压力性损伤预防护理最佳证据的应用审查及障碍分析

Application Review and Barrier Analysis of the Best Evidence for the Preventive Care of Nasal Mucosal Pressure Injury in ICU Patients with Nasal Tube Placement

摘要

目的 了解重症监护室经鼻置管患者预防鼻黏膜压力性损伤证据临床应用现状，制定审查指标，分析障碍及促进因素，并据此制定变革策略。方法 依据乔安娜·布里格斯研究所（Joanna Briggs institute，JBI）循证卫生保健模式，形成预防经鼻置管患者鼻黏膜压力性损伤的最佳护理策略，据此制订审查指标并于2025年3月至6月选取昆明市某三甲医院ICU经鼻置管患者60例及重症医学科护士27名进行临床审查，根据i-PARIHS概念框架理论，从“变革、变革接受者及组织环境”三方面剖析实践推进阶段的障碍与促进因素，构建相对应的实施策略。结果 最终纳入20项最佳证据，并据此制定30项审查指标。仅有8项指标达成100%的临床执行率，9项指标临床执行率不足60%，另有11项指标的临床执行率为零。分析障碍因素主要为：缺乏对应的评估及护理流程、护理人员对鼻腔护理的重视程度欠缺以及培训考核机制尚不成熟等；促进因素包括护士态度积极、医护配合良好、变革领导者大力支持、科研基础扎实等。实施相应对策后，30条审查指标中27条依从率为100%。结论 鼻黏膜压力性损伤预防的循证证据与临床应用之间存在着明显的脱节，精准梳理实践推进过程中的有利条件与阻碍原因，配套落实干预举措，可有效促进循证证据融入临床工作。

Abstract

Objective To evaluate the current clinical application of evidence for preventing nasal mucosal pressure injury in patients with nasal catheterization in the intensive care unit, develop audit criteria, analyze obstacles and facilitating factors, and formulate corresponding improvement strategies. Methods According to the JBI evidence-based healthcare model, best nursing strategies for the prevention of nasal mucosal pressure injury in patients with nasal tube placement were developed. Corresponding audit criteria were formulated, and a clinical audit was conducted from March to June 2025, involving 60 ICU patients with nasal tube placement and 27 nurses from the Department of Critical Care Medicine in a tertiary hospital in Kunming. According to the i-PARIHS conceptual framework, obstacles and facilitators during the implementation phase were analyzed from three aspects: "innovation, recipients and context", and the corresponding implementation strategies were constructed. Results A total of 20 pieces of best evidences were ultimately included, based on which 30 audit criteria were developed. Only 8 criteria achieved 100% clinical compliance, 9 criteria had compliance rate below 60%, and another 11 criteria had a clinical compliance rate of zero. Major obstacles included the lack of corresponding evaluation and nursing process, insufficient attention to nasal care among nursing staff, and immature training and assessment mechanisms. Facilitators included positive attitude of nurses, good cooperation between medical and nursing care, strong support from change leaders, and a solid scientific research foundation. After implementing the targeted strategies, 27 of the 30 audit criteria reached 100% compliance. Conclusion There is a significant gap between the evidence for the prevention of nasal mucosal pressure injury and its clinical application. Accurately identifying facilitators and obstacles in the implementation process and implementing targeted interventions can effectively promote the integration of evidence-based practices into clinical care.

关键词

重症医学科 / 经鼻置管 / 鼻黏膜压力性损伤 / 审查指标 / 障碍因素 / 循证实践

Key words

Department of Critical Care Medicine / Nasal intubation / Pressure injury of nasal mucosa / Audit criteria / Barriers / Evidence-based practice

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基金资助

昆明医科大学硕士研究生教育创新基金(2025S211)

昆明医科大学教育教学研究课题(2024-JY-Y-152)